Background Giant left atrium (GLA) is a rare complication of rheumatic heart disease that may continue to enlarge despite successful valve surgery. Case Summary A 69-year-old man with rheumatic valvular disease and previous mechanical mitral and aortic valve replacement developed progressive GLA and heart failure symptoms. Redo aortic valve replacement was performed for prosthetic dysfunction. Long-term follow-up demonstrated progressive atrial enlargement (indexed left atrial volume up to 1,172 mL/m2), mediastinal displacement, and pulmonary compression. Despite these findings, right heart catheterization confirmed normal pulmonary artery and filling pressures, with preserved left ventricular ejection fraction and sustained clinical stability. Discussion GLA is typically associated with pulmonary hypertension and heart failure progression. This case is notable for extreme progressive atrial remodeling over 2 decades despite correction of the underlying valve disease, while preserving pulmonary hemodynamics and ventricular function. Take-Home Messages Progressive GLA may remain compatible with prolonged survival after successful valve surgery when ventricular function and pulmonary hemodynamics are preserved. Long-term multimodality imaging and invasive hemodynamic assessment are essential for patient management.

Percutaneous microaxial flow pumps have become an important form of temporary mechanical circulatory support for patients with advanced cardiac dysfunction, particularly in cardiogenic shock and high-risk percutaneous coronary intervention. By actively unloading the ventricle, reducing end-diastolic pressure and myocardial oxygen demand, and supporting systemic and coronary perfusion, Impella devices offer distinct physiological advantages over passive support strategies. This state-of-the-art review summarizes the mechanisms of ventricular unloading, device characteristics, procedural considerations, monitoring requirements, complication management, and contemporary clinical applications of axial-flow percutaneous ventricular assist devices. Current evidence suggests that, in selected patients with infarct-related cardiogenic shock, early and protocolized Impella use may improve survival, although this benefit must be balanced against higher rates of bleeding, hemolysis, vascular injury, thrombosis, and device-related complications. In high-risk percutaneous coronary intervention, Impella may enhance procedural stability and facilitate more complete revascularization, but a definitive survival benefit remains unproven. Emerging applications include right ventricular support, biventricular support, postcardiotomy shock prevention, ventricular tachycardia ablation, and combined use with venoarterial extracorporeal membrane oxygenation. Despite expanding use, major uncertainties remain regarding optimal timing, patient selection, standardized anticoagulation and weaning protocols, cost-effectiveness, and generalizability beyond infarct-related shock. Further randomized trials, registry-based analyses, and technological refinements are needed to define which patients benefit most while minimizing complications.

Background: The NeoChord procedure is a trans-ventricular, echo-guided, beating-heart mitral valve (MV) repair technique used to treat degenerative mitral regurgitation (MR) caused by leaflet prolapse and/or flail. Objectives: This study aimed to develop a machine learning (ML) scoring system using pre-procedural clinical and echocardiographic variables to predict the success of the NeoChord procedure—defined as less than moderate MR at follow-up. Methods: A total of 80 patients were included. Preoperative MV anatomical parameters were assessed using three-dimensional (3D) transesophageal echocardiography and analyzed with dedicated post-processing software (QLAB software, version 15.0, Philips Healthcare, Amstelveen, NL, The Netherlands). Two supervised ML models (random forest and decision tree) were trained on the dataset, with hyperparameters optimized via 10-fold cross-validation. The random forest model also provided a variable importance ranking using a filter-based method. Key predictors identified by the models included age, flail gap, early systolic mitral valve area, and indexed left atrial volume. Results: The mean and median cross-validated area under the curve of the ML models were 0.79 and 0.83 for the random forest model and 0.72 and 0.77 for the decision tree model, respectively. Conclusions: A machine learning approach integrating clinical and 3D echocardiographic parameters can effectively predict mid-term procedural success of the NeoChord technique. This method may support future preoperative patient selection, pending validation in larger cohorts.

OBJECTIVE Recurrence of mitral valve (MV) regurgitation after prior repair remains a challenge, even in experienced centers. Reoperation is associated with increased morbidity and mortality risks, prompting the exploration of less-invasive alternatives. This study aimed to compare outcomes in patients with failed MV repair undergoing open-heart surgery (OHS) versus micro-invasive re-repair using neochordae (Neochord). METHODS Thirty-seven patients were retrospectively enrolled: 22 underwent OHS and 15 underwent Neochord repair. All patients had recurrent MV prolapse following prior annuloplasty. The primary endpoint was freedom from a composite event, defined as mitral valve reoperation or the presence of moderate-or-severe mitral regurgitation at 1 year. IRB: 0001455, date of approval October 19, 2022. All patients provided informed written consent for the publication of their data. RESULTS Baseline characteristics, including mean age (63.9±8.5 vs 67.5±7.8 years, p=0.210), female gender (27.3% vs 26.7%, p>0.99), left ventricular ejection fraction (57.6±8.2% vs 58.7±4.3%, p=0.574), and EuroSCORE II (4.3±2.9% vs 3.4±1.4%, p=0.632), were comparable between the two groups. In the OHS group, 40.9% of surgeries were performed via sternotomy, and 54.5% required MV replacement. All Neochord procedures were successfully performed via left mini-thoracotomy. Operative time was significantly longer for OHS (310.2±79.2 vs 146.1±30.7 minutes, p<0.0001). There were no 30-day mortalities. One patient in the OHS group experienced a disabling stroke, and one patient in each group required re-exploration for bleeding. Blood transfusion requirements were significantly higher with OHS (1.5±2.1 vs 0.1±0.5 units, p=0.012). Neochord patients had significantly shorter ventilation times (12 vs 3 hours, p<0.0001) and hospital stays (6 vs 4 days, p<0.0001). Follow-up echocardiographic findings and cardiovascular readmissions were comparable between the two groups. CONCLUSIONS In patients with recurrent prolapse after MV repair, Neochord re-repair offers comparable 1-year outcomes to OHS, with significantly faster recovery and reduced transfusion needs.

Objective: Recurrence of mitral valve regurgitation after prior repair remains a challenge, even in experienced centers. Reoperation is associated with increased morbidity and mortality risks, prompting the exploration of less-invasive alternatives. This study aimed to compare outcomes in patients with failed mitral valve repair undergoing on-pump surgery versus micro-invasive re-repair surgery using neochordae (the NeoChord system). Methods: Thirty-seven patients were retrospectively enrolled; 22 patients underwent on-pump surgery, and 15 patients underwent NeoChord repair. All patients had recurrent mitral valve prolapse after prior annuloplasty. The primary end point was freedom from a composite event, defined as mitral valve reoperation or the presence of moderate-or-severe mitral regurgitation at 1 year. All patients provided informed written consent for the publication of their data. Results: Baseline characteristics, including mean age (63.9 ± 8.5 vs 67.5 ± 7.8 years, P = .210), female gender (27.3% vs 26.7%, P > .99), left ventricular ejection fraction (57.6% ± 8.2% vs 58.7% ± 4.3%, P = .574), and European System for Cardiac Operative Risk Evaluation II (4.3% ± 2.9% vs 3.4% ± 1.4%, P = .632), were comparable between the 2 groups. In the on-pump surgery group, 40.9% of surgeries were performed via sternotomy, and 54.5% required mitral valve replacement. All NeoChord procedures were successfully performed via left minithoracotomy. Operative time was significantly longer for on-pump surgery (310.2 ± 79.2 vs 146.1 ± 30.7 minutes, P < .0001). There were no 30-day mortalities. One patient in the on-pump surgery group experienced a disabling stroke, and 1 patient in each group required reexploration for bleeding. Blood transfusion requirements were significantly higher with on-pump surgery (1.5 ± 2.1 vs 0.1 ± 0.5 units, P = .012). Patients undergoing NeoChord procedure had significantly shorter ventilation times (12 vs 3 hours, P < .0001) and hospital length-of-stay (6 vs 4 days, P < .0001). Follow-up echocardiographic findings and cardiovascular readmissions were comparable between the 2 groups. Conclusions: In patients with recurrent prolapse after mitral valve repair, NeoChord re-repair offers comparable 1-year outcomes to on-pump surgery, with significantly faster recovery and reduced transfusion needs.

Several techniques of aortic valve (AV) repair have shown safety and efficacy. One of the main contraindications to AV repair is still the presence of cusps calcification. Piezoelectric effect can be used to selectively cut calcium while sparing surrounding soft tissues addressing also complex valves with calcified cusps. Here we present a case of a 55-year-old woman with diagnosis of severe AV regurgitation and dilated ascending aorta who was suitable for aortic valve repair. The trans-esophageal echocardiography (TEE) showed a tricuspid AV with severe regurgitation and a partial fusion of right and non-coronary cusps with mild calcification of the raphe, which could compromise a successful repair. The raphe was shaved with a piezoelectric scalpel until a pliable surface was obtained and post-procedural TEE showed a trivial residual AV regurgitation. This tool can help surgeons to face also complex cases considered not suitable for a conservative technique.

Bonalumi and co-authors, on behalf of the COVID-SICCH Task Force of the Italian Society for Cardiac Surgery, addressed the very particular and difficult moment experienced by cardiac surgery during the first wave of the coronavirus disease 2019 (COVID-19) pandemic.1 The authors should be commended for their effort to analyze and summarize the various guidelines implemented worldwide with the aim to improve the reorganization of cardiac surgical departments. In their article, the authors comment on the different models proposed for the reallocation of resources and their effective application in clinical practice, outlining close interrelationships between cardiac operations performed in the midst of the pandemic and pandemic-related clinical events, most typically those related to the prothrombotic state determined by COVID-19. Italy was the first Western country hit by the initial outbreak of the COVID-19 pandemic, prompting the government to introduce restrictive measures and lockdown on 8 March 2020. The strain on an unprepared healthcare system determined near-saturation of intensive care beds in the northern regions, Lombardy in particular, and a consequent impossibility to guarantee regular hospital activity, with an obvious impact also on cardiac surgery. In this scenario, hospitals turned into hubs and spokes with an overall reduction of elective hospitalizations nationwide, with a synergy rather than a distinction between the two strategies to face the emergency, that is, hub-and-spoke vs. overall reduction. In most Italian regions, tertiary care centers remained hubs and highly specialized activity, including cardiac surgery, was temporarily stopped in minor centers, which were turned into spokes and COVID-19 hospitals. In Lombardy, conversely, hubs and spokes were determined on political grounds by the regional government with somewhat different criteria (DGR n. XI/2906 – Regione Lombardia). In brief, hospitals in Lombardy were rearranged according to four major fields for the referral of nondeferrable patients: major trauma and neurosurgery, stroke units, interventional cardiovascular procedures and cardiovascular surgery. For the latter, hubs needed to guarantee three concomitant operating rooms, 24-h acceptance and COVID-free pathways, including dedicated intensive care beds. Not all hospitals with these capabilities, however, were considered as hubs and cardiac operations were performed in only four centers in a region with a near-10 million population. Interestingly, three of four hubs were private hospitals with prior accreditation with the regional health system to provide a public service reimbursed by the regional government. Among them, one of the hubs is an academic hospital specialized in cardiovascular disease. On the other hand, in contrast to other Italian regions, the three public tertiary care centers performing heart transplantation in Lombardy were not authorized to continue regular surgical activity during the first outbreak of the pandemic. Worldwide, a global reduction in elective surgery was constantly observed, with peaks in urban areas.2–6 The strategies to tackle the pandemic were also a consequence of different healthcare systems. A reduction of hospital admissions regarding typical cardiovascular emergencies was observed, especially during the first outbreak of the COVID-19 pandemic.7 More specifically, admissions for acute coronary syndromes dropped significantly.8–11 In parallel, an increase in mechanical complications of myocardial infarction was observed at different institutions,12–14 indicating late presentation of evolved and untreated patients, a clinical scenario that goes back to the seventies. Similarly, the number of potential and actual organ donors in 2020 vs. 2019 decreased by 12.8 and 10.4%, respectively, on a national basis (data from the Sistema Informativo Trapianti, SIT) with a decrease in heart transplantation activity by 2.9% nationwide. In this scenario, Lombardy was the most affected region with a near-30% reduction in overall transplants, whereas donors increased in most of the other northern and some of the central Italian regions. Similar considerations apply to acute aortic syndromes, with fewer acute dissections observed during the outbreak, and to other fields of medical care, including delayed diagnosis of cancer.15 A key aspect addressed by Bonalumi et al. is the extreme difficulty, during the outbreak of the pandemic, in separating and clearly discerning fatal events directly because of COVID-19 from those related to other undiagnosed conditions, as many patients, especially in case of known cardiac disease, were advised to ‘remain home’ for fear of being infected. In turn, the general reluctance of patients towards hospitals, emergency departments in particular, magnified this phenomenon. The creation of separate pathways has been a mandatory and obvious step in the management and isolation of COVID-positive vs. negative patients. However, a grey zone regarding potentially infected patients and the development of a positive swab during hospitalization is inevitable. Bronchoalveolar lavage has been shown to provide a higher diagnostic accuracy for the detection of SARS-CoV2 and some institutions employed it routinely in surgical or other intubated patients after nonelective hospitalization with the impossibility to perform a nasopharyngeal screening swab during the preceeding 48–72 h.16 Another issue relates to the opportunity to operate on COVID-positive patients presenting with nondeferrable conditions. Evidence supports a higher operative risk in cardiac surgical candidates, likely not only because of an increased rate of respiratory complications in case of overt COVID-related pneumonia but also because of thrombotic complications.17 Interestingly, a potentially protective role of postoperative anticoagulation has been suggested in patients developing COVID-19 after cardiac operations.18 Finally, extracorporeal membrane oxygenation (ECMO) as an extreme resource was used to treat refractory respiratory failure in COVID-19. Although cardiac surgeons are not invariably involved, some areas are organized with centralized ECMO teams constituted of anesthesiologists and cardiac surgeons, and patients are transferred to a hub hospital. This setting not only applies to veno-arterial ECMO for cardiogenic shock but also to venovenous ECMO for acute respiratory distress syndrome (ARDS) and respiratory failure. During the pandemic, for instance, the ECMO team from Turin treated over 50 patients with COVID-related pneumonia throughout Piedmont. A similar number of ECMO implants in COVID patients was carried out by the team from Pavia. Results were dismal and nonhomogenous during the initial outbreak, with very poor overall survival, most likely secondary to late and compassionate indications for ECMO in unselected patients. More targeted indications for the allocation of this socially expensive resource determined a gradual improvement in outcomes with survival rates of over 50%.19 Noteworthily, mortality is near-double in comparison to ECMO support for ARDS secondary to H1N1 influenza.20 In conclusion, COVID-19 hampered healthcare systems worldwide at various levels, with up to 70–80% reduction of surgical activity during the initial lockdown period. Cardiac operations were no exception. Investment in health system resources has been lacking for too many years and is a crucial issue to face and, hopefully, prevent similar scenarios in the future. Every effort should now be focused to a ‘return-to-normal’,21,22 taking into account that the postponement of elective surgery not only affects the probability of cardiac-related death and adverse events while on the waiting list, but also determines longer intensive care length of stay and prolonged hospitalization related to the higher complexity of more urgent patients. Conflicts of interest There are no conflicts of interest.

OBJECTIVE:Transventricular beating-heart mitral valve repair (TBMVR) with artificial chordae implantation is a technique to treat mitral valve prolapse. Two-dimensional (2D) echocardiography completed with simultaneous biplane view during surgeon finger pushing on the left ventricular (LV) wall (finger test [FT]) is currently used to localize the desired LV access, on the inferior-lateral wall, between the papillary muscles (PMs). We aimed to compare a new three-dimensional (3D) method with conventional FT in terms of safety and better localization of LV access.METHODS:During TBMVR, conventional FT was completed using 3D transesophageal echocardiography by placing the sample box in the bicommissural view of the LV, including the PMs and the apex. The 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator's finger pushing on the LV. We asked the first operator, the second operator, and the cardiac surgery fellow, separately, to evaluate the location of their finger pushing, both with the 2D method and the 3D method, to estimate the interoperator concordance.RESULTS:From 2019 to 2021, 42 TBMVRs were performed without complications related to access using FT completed with the 3D method. Regarding the choice of the right and safe entry site, the operator's agreement was higher using 3D rendering compared with conventional FT (mean agreement 0.59 ± 0.29 for 2D vs 0.83 ± 0.20 for 3D), while full operator agreement was 10 of 42 for 2D and 23 of 42 for 3D (P = 0.004).CONCLUSIONS:Three-dimensional FT is easy to perform and facilitates surgeons choosing the best access for TBMVR in term of anatomical localization and safety.